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Mental Health

In early 19th century America, care for the mentally ill was almost non-existent: the afflicted were usually relegated to prisons, almshouses, or
inadequate supervision by families. Treatment, if provided, paralleled other medical treatments of the time, including bloodletting and
purgatives. However, in a wave of concern for the oppressed, some took action. Among these, Dorothea Dix was the leading crusader for the
establishment of state-supported mental asylums. Through her efforts, the first state hospitals for the insane were built in New Jersey and
Pennsylvania. She and other reformers sought humane, individualized care with the rich and the poor housed together to insure high standards for
all. The movement was generated by social reform, but throughout the century, mental illness was probed and analyzed, and "cures" prescribed by
both the scientific and lay communities.

"Moral treatment" was the predominating philosophy to cure the insane. This system was developed in late 18th century Europe, and by Benjamin Rush
in the United States. It challenged the demonic explanations for insanity and emphasized the role of environment in determining character:
improper external conditions could induce derangement. The "moral treatment" system was optimistic that an appropriate environment could
facilitate cure, especially for those with acute (not chronic) afflictions.

Essential to this theory was a physiological basis for mental disorder: insanity was caused by brain damage. The brain's surface was soft and
malleable and physically altered by outward influence. This idea was closely related to phrenology which assigned specific faculties to sections
of the brain.

The notion that mental illness resulted from physical impairment was rarely challenged, but the nature and treatment of ailments were continually
debated. To find physical evidence for mental deficiencies, autopsies were performed on mental patients to discover lesions or other
abnormalities. Although progress was made in the diagnosis of somatic diseases like tumors or syphilitic derangement, these efforts were
frustrating and subjective. Also controversial was the fate of the chronically versus acutely ill: the differences between them, whether they
should be housed together, and whether the chronically ill should be treated at all.

Superintendents of early mental institutions were well educated, although not necessarily in medicine, and active in the community. Thirteen heads
of institutions, called "alienists," formed the Association of Medical Superintendents, and began the American Journal of Insanity.
Asylums were built in rural areas to remove patients from their home environments and to provide fresh air in a bucolic setting. Patients were
offered exercise, work, education, and religious instruction. Most alienists did not dispense drugs, but stressed healthy, clean living. They
lived near patients, invited the public in for programs, and promoted the view that the insane were not monsters but rather "unfortunate fellow
beings." Focusing on societal causes, alienists believed mental health problems could be avoided, especially in the young: children's brains were
softer, vulnerable, and more prone to influence.

After the Civil War, faith in "moral treatment" declined because the curability rate had been overestimated, the cost of facilities was high, the
government curtailed funds, and the public became disillusioned with "experts" and their failed promises. Repeated failures also frustrated
practitioners who responded with an increased use of physical restraint. An influx of immigrants caused overcrowding and a loss of fee-paying
private patients. As the medical field was slow to become interested in the care of the mentally ill, there was a lack of trained personnel. The
original, more idealistic practitioners were gone, and new managers, many of whom were political appointees, were less inspired and qualified.
These alienists became self-protective and isolated from the public. They also feared that "moral treatment" was responsible for the rise in
spiritualist movements, considered fanatical and dangerous, and they further tightened the reins of custodial care.

Between 1850 and 1880, viewpoints reverted back to pre-asylum assessments, with the added element of heredity: mental illness resulted from a weak
family and vice committed by ancestors. This led to a fatalistic view of cures, and a new wave of books detailing the dangers of bad habits such
as alcoholism and masturbation. Influenced by Social Darwinism, practitioners believed mental illness could be eliminated through eugenics.
Although there were scientific advances, particularly in neurology, the tendency was to classify ailments rather than investigate through
observation. Drugs such as chloroform, bromides, and ether were increasingly used to subdue patients.

By the 1880s, asylum conditions had deteriorated significantly, and neurologists began to vie for control of institutions. They opposed
superintendents and questioned the validity of the asylum itself, promoting the clinic instead. In 1880 they formed the National Association of
the Insane and the Prevention of Insanity. A public interest in reform ensued with exaggerated stories of asylum abuse appearing in newspapers.
By 1884 the neurologists and superintendents were forced into an uneasy truce resulting in medical standards for superintendents, greater control
over asylums, oversight commissions, psychopathic hospitals for the acute, out-patient care, and research. Medical education began to include the
study of insanity. The word "asylum" was replaced by "hospital" to reduce the stigma of mental illness.

Neurologists made some sound contributions to the field, but they also promoted dubious treatments such as static electricity and the "rest cure."
Eventually, neurologists formed two camps: those who focused on somatic cases, and those who embraced psychological theories as medically
respectable.

To remove the chronically ill from overcrowded asylums and in a general effort to promote non-restraint, alternative care facilities such as the
tent treatment, the free air system, and the cottage system were attempted in the latter part of the century. The Toledo (Ohio) State Hospital
was the first mental health institution in the country to be designed exclusively on the cottage system. In spite of such reform efforts, the
dominance of Social Darwinism condemned the chronically ill as genetically inferior. It was not until the final years of the century that Sigmund
Freud's theories about the unconscious crept into the professional arena.

Ranney, Ambrose L. Lectures on Nervous Diseases: From the Standpoint of Cerebral and Spinal Localization, and the Later Methods Employed in the
Diagnosis and Treatment of These Affections. Philadelphia: F. A. Davis, 1890. MCO

Walker, Alexander. Intermarriage: Or the Mode in Which, and the Causes Why, Beauty, Health and Intellect, Result from Certain Unions, and
Deformity, Disease and Insanity, from Others. New York: J. H. G. Langley, 1839.